General Discussion
Related: Editorials & Other Articles, Issue Forums, Alliance Forums, Region ForumsI found the Health Care premium tables....holy Sh*T
This table shows you how much a month the Health Act premiums are for:
Your state and county,
the Level of plan ( Silver,Gold, Bronze,Platinum and Catastrophic,
and the age ranges and family size of the premium for people living in your county.
And..it looks like Blue Cross Blue Shield is the primary company used...they are gonna get a LOT of money.
So, I went to my county.
Monthly Silver ( lowest) Premium for a 27 y/o adult=192.93
Annual Premium therefore is........$2,315.16
Monthly Silver ( lowest) Premium for a 50+ y/o adult=327.50
Annual Premium therefore is........$3,930.00
Monthly Silver ( lowest) Premium for a family=649.34
Annual Premium therefore is.....$7,792.00
This, in a county with over 12% unemployment, where the average annual wage is $28,486
( see this site for help with stats...http://www.city-data.com)
Starting wages for Police Academy graduates here is 8.25 an hour.
Here is link....it might be interesting to hear what the cost is in your neck of the woods.
It is a table, so once you click on your county and insurance plan, you have arrow key over to the right
so the cost numbers show up for different age and family groups.
https://data.healthcare.gov/dataset/QHP-Individual-Medical-Landscape/ba45-xusy
whadda ya think?
Sedona
(3,769 posts)dkf
(37,305 posts)Just like insurance costs that your employer pays, it seems lower because someone else foots the bulk of the bill.
Thank you
No one EVER brings that up
lumberjack_jeff
(33,224 posts)Because of ACA, and the minimum loss ratio, Insurance companies get far less profit than previously.
These aren't new costs, they are just spread more equitably.
dkf
(37,305 posts)Our employer based system hides a lot of the cost but in the end it is less pay for us to receive.
lumberjack_jeff
(33,224 posts)nor is it enriching insurers to a greater extent than the previous (absence of) regulations.
dkf
(37,305 posts)The problem with the ACA is a lack of cost control measures.
uppityperson
(115,677 posts)They will not make much money off of me.
lumberjack_jeff
(33,224 posts)uppityperson
(115,677 posts)lumberjack_jeff
(33,224 posts)Warren Stupidity
(48,181 posts)2. One of the reasons for expansion and mandates is to get more healthy people into the system, which will lower per capita costs.
3. More use can lower unit costs.
lumberjack_jeff
(33,224 posts)And now that customers can compare insurance offerings apples to apples, they will help to control costs.
NoOneMan
(4,795 posts)Muddled theories. We don't actually know if 1) the market place full of anti-trust exempt insurers will stop the the growth in health insurance costs, 2) people with high-deductible, high-copay plans will be any less likely to self-ration until the last moment and end up in the ER.
Its going to take years to know how this pans out. Stating these talking points as facts is misguided
lumberjack_jeff
(33,224 posts)1) checkups are now covered for free. People who get preventive care will be less likely to end up in the ER, and people with meaningful illnesses caught during those checkups are less likely to go to the ER or to defer care until it's too late.
2) someone with a major illness will find a $7000 deductible inconvenient, but it won't cost them their home.
3) the insurers aren't choosing to stop the growth in insurance costs, they will be forced by consumer pressure. Customers will choose the cheapest insurance in the exchange. Not the cheapest insurer? No market share. And you can't extort money from your current customers by jacking the year two rates because the customer can simply change companies, regardless of their preexisting conditions. Providers don't want to be priced out of the market either.
NoOneMan
(4,795 posts)There is some good tinkering with a batshit insane shithole system. But its underwhelming and the system remains batshit insane
lumberjack_jeff
(33,224 posts)It's better than last year.
I think it's likely to be better next year.
Personally, that's all I demand from government. I consider it a win.
ailsagirl
(22,897 posts)JDPriestly
(57,936 posts)grantcart
(53,061 posts)There are lots of cost control measures with the ACA not the least of which is controlling the MLR.
That you would compare the ACA in its infancy with a single payer system that is 40 years in its development as some kind of argument is an astounding exercise in spouting nonsense.
Let's not bother with details but go to the heart of the matter:
Moving from Fee for Service.
All experts agree that this is the most important source of controlling costs for the American Health system.
The PPACA invests billions in developing practical ways to move from fee for service models to global budgets.
from a Harvard analysis:
http://news.harvard.edu/gazette/story/2012/07/moving-beyond-health-cares-fee-for-service/
Researchers from Harvard Medical Schools Department of Health Care Policy have analyzed claims data from Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), a global budget program in which 11 health care provider organizations were given a budget to care for patients who use Blue Cross Blue Shield of Massachusetts insurance. Such a model contrasts with widely used fee-for-service systems, where providers are reimbursed for each medical service they deliver.
The AQC predates, but is similar to, the Pioneer Accountable Care Organization contracts that Medicare began this year through the Affordable Care Act, an initiative in which Medicare will reward groups of providers based on improved outcomes and lower health care spending.
The researchers looked at the first two years of data from the AQC and found that the program has, in fact, succeeded in lowering total medical spending while simultaneously improving quality of care.
On average, groups in the AQC spent 3.3 percent less than fee-for-service groups in the second year, the study showed. Provider groups that entered AQC from a traditional fee-for-service contract model achieved even greater spending reductions of 9.9 percent in year two, up from 6.3 percent in the first year. Compared with those groups, groups that entered from contracts that were already similar to the AQC achieved fewer savings in both years. The researchers also found that the improvements in quality of chronic care management, adult preventive care, and pediatric care associated with the AQC grew in the second year.
Moving away from fee-for-service models is high on the agenda of those looking to establish a fiscally sustainable, efficient health care system, said Michael Chernew, professor of health care policy at Harvard Medical School (HMS) and senior author on the study. It is likely that this type of new payment model will grow rapidly in coming years in the nation as a whole, and particularly in Massachusetts. By analyzing this program, were studying the future before it gets here.
Now where in the PPACA might we find this?
Here is a link to the legislation:
http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf
And we find that Title III is labeled: Improving the Quality and Efficiency of Health Care.
SubTitle A: Transforming the Health Care Delivery System
You can find a 13 page chart which analyzes the impact on Title III on transforming from fee for service to other models of health care here:
http://www.nasuad.org/documentation/aca/NASUAD_materials/title_III_analysis.pdf
Here is a small part of Title III and just a few of the components related to completely transforming the fee for service basis of the American Health Care System:
Again here is your statement:
The problem with the ACA is a lack of cost control measures.
Here are the actual facts from the PPACA:
http://en.wikisource.org/wiki/Patient_Protection_and_Affordable_Care_Act/Title_III/Subtitle_A/Part_III
PART III--ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS
SEC. 3021. ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID INNOVATION WITHIN CMS.[edit]
(a) In General- Title XI of the Social Security Act is amended by inserting after section 1115 the following new section:`CENTER FOR MEDICARE AND MEDICAID INNOVATION`Sec. 1115A. (a) Center for Medicare and Medicaid Innovation Established- `(1) IN GENERAL- There is created within the Centers for Medicare & Medicaid Services a Center for Medicare and Medicaid Innovation (in this section referred to as the `CMI') to carry out the duties described in this section. The purpose of the CMI is to test innovative payment and service delivery models to reduce program expenditures under the applicable titles while preserving or enhancing the quality of care furnished to individuals under such titles. In selecting such models, the Secretary shall give preference to models that also improve the coordination, quality, and efficiency of health care services furnished to applicable individuals defined in paragraph (4)(A).`(2) DEADLINE- The Secretary shall ensure that the CMI is carrying out the duties described in this section by not later than January 1, 2011.`(3) CONSULTATION- In carrying out the duties under this section, the CMI shall consult representatives of relevant Federal agencies, and clinical and analytical experts with expertise in medicine and health care management. The CMI shall use open door forums or other mechanisms to seek input from interested parties.`(4) DEFINITIONS- In this section: `(A) APPLICABLE INDIVIDUAL- The term `applicable individual' means-- `(i) an individual who is entitled to, or enrolled for, benefits under part A of title XVIII or enrolled for benefits under part B of such title;`(ii) an individual who is eligible for medical assistance under title XIX, under a State plan or waiver; or`(iii) an individual who meets the criteria of both clauses (i) and (ii).`(B) APPLICABLE TITLE- The term `applicable title' means title XVIII, title XIX, or both.`(b) Testing of Models (Phase I)- `(1) IN GENERAL- The CMI shall test payment and service delivery models in accordance with selection criteria under paragraph (2) to determine the effect of applying such models under the applicable title (as defined in subsection (a)(4)(B)) on program expenditures under such titles and the quality of care received by individuals receiving benefits under such title.`(2) SELECTION OF MODELS TO BE TESTED- `(A) IN GENERAL- The Secretary shall select models to be tested from models where the Secretary determines that there is evidence that the model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures. The models selected under the preceding sentence may include the models described in subparagraph (B).`
(B) OPPORTUNITIES- The models described in this subparagraph are the following models: `(i) Promoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable individuals, medical homes that address women's unique health care needs, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment.`(ii) Contracting directly with groups of providers of services and suppliers to promote innovative care delivery models, such as through risk-based comprehensive payment or salary-based payment.`(iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of applicable individuals with multiple chronic conditions and at least one of the following: `(I) An inability to perform 2 or more activities of daily living.`(II) Cognitive impairment, including dementia.`(iv) Promote care coordination between providers of services and suppliers that transition health care providers away from fee-for-service based reimbursement and toward salary-based payment.`(v) Supporting care coordination for chronically-ill applicable individuals at high risk of hospitalization through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health technology.`(vi) Varying payment to physicians who order advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)) according to the physician's adherence to appropriateness criteria for the ordering of such services, as determined in consultation with physician specialty groups and other relevant stakeholders.`(vii) Utilizing medication therapy management services, such as those described in section 935 of the Public Health Service Act.`(viii) Establishing community-based health teams to support small-practice medical homes by assisting the primary care practitioner in chronic care management, including patient self-management, activities.`(ix) Assisting applicable individuals in making informed health care choices by paying providers of services and suppliers for using patient decision-support tools, including tools that meet the standards developed and identified under section 936(c)(2)(A) of the Public Health Service Act, that improve applicable individual and caregiver understanding of medical treatment options.`(x) Allowing States to test and evaluate fully integrating care for dual eligible individuals in the State, including the management and oversight of all funds under the applicable titles with respect to such individuals.`(xi) Allowing States to test and evaluate systems of all-payer payment reform for the medical care of residents of the State, including dual eligible individuals.`(xii) Aligning nationally recognized, evidence-based guidelines of cancer care with payment incentives under title XVIII in the areas of treatment planning and follow-up care planning for applicable individuals described in clause (i) or (iii) of subsection (a)(4)(A) with cancer, including the identification of gaps in applicable quality measures.`(xiii) Improving post-acute care through continuing care hospitals that offer inpatient rehabilitation, long-term care hospitals, and home health or skilled nursing care during an inpatient stay and the 30 days immediately following discharge.`(xiv) Funding home health providers who offer chronic care management services to applicable individuals in cooperation with interdisciplinary teams.`(xv) Promoting improved quality and reduced cost by developing a collaborative of high-quality, low-cost health care institutions that is responsible for-- `(I) developing, documenting, and disseminating best practices and proven care methods;`(II) implementing such best practices and proven care methods within such institutions to demonstrate further improvements in quality and efficiency; and`(III) providing assistance to other health care institutions on how best to employ such best practices and proven care methods to improve health care quality and lower costs.`(xvi) Facilitate inpatient care, including intensive care, of hospitalized applicable individuals at their local hospital through the use of electronic monitoring by specialists, including intensivists and critical care specialists, based at integrated health systems.`(xvii) Promoting greater efficiencies and timely access to outpatient services (such as outpatient physical therapy services) through models that do not require a physician or other health professional to refer the service or be involved in establishing the plan of care for the service, when such service is furnished by a health professional who has the authority to furnish the service under existing State law.`(xviii) Establishing comprehensive payments to Healthcare Innovation Zones, consisting of groups of providers that include a teaching hospital, physicians, and other clinical entities, that, through their structure, operations, and joint-activity deliver a full spectrum of integrated and comprehensive health care services to applicable individuals while also incorporating innovative methods for the clinical training of future health care professionals.`
(C) ADDITIONAL FACTORS FOR CONSIDERATION- In selecting models for testing under subparagraph (A), the CMI may consider the following additional factors: `(i) Whether the model includes a regular process for monitoring and updating patient care plans in a manner that is consistent with the needs and preferences of applicable individuals.`(ii) Whether the model places the applicable individual, including family members and other informal caregivers of the applicable individual, at the center of the care team of the applicable individual.`(iii) Whether the model provides for in-person contact with applicable individuals.`(iv) Whether the model utilizes technology, such as electronic health records and patient-based remote monitoring systems, to coordinate care over time and across settings.`(v) Whether the model provides for the maintenance of a close relationship between care coordinators, primary care practitioners, specialist physicians, community-based organizations, and other providers of services and suppliers.`(vi) Whether the model relies on a team-based approach to interventions, such as comprehensive care assessments, care planning, and self-management coaching.`(vii) Whether, under the model, providers of services and suppliers are able to share information with patients, caregivers, and other providers of services and suppliers on a real time basis.`(3) BUDGET NEUTRALITY- `(A) INITIAL PERIOD- The Secretary shall not require, as a condition for testing a model under paragraph (1), that the design of such model ensure that such model is budget neutral initially with respect to expenditures under the applicable title.`(B) TERMINATION OR MODIFICATION- The Secretary shall terminate or modify the design and implementation of a model unless the Secretary determines (and the Chief Actuary of the Centers for Medicare & Medicaid Services, with respect to program spending under the applicable title, certifies), after testing has begun, that the model is expected to-- `(i) improve the quality of care (as determined by the Administrator of the Centers for Medicare & Medicaid Services) without increasing spending under the applicable title;`(ii) reduce spending under the applicable title without reducing the quality of care; or`(iii) improve the quality of care and reduce spending. Such termination may occur at any time after such testing has begun and before completion of the testing. `(4) EVALUATION- `(A) IN GENERAL- The Secretary shall conduct an evaluation of each model tested under this subsection. Such evaluation shall include an analysis of-- `(i) the quality of care furnished under the model, including the measurement of patient-level outcomes and patient-centeredness criteria determined appropriate by the Secretary; and`(ii) the changes in spending under the applicable titles by reason of the model.`(B) INFORMATION- The Secretary shall make the results of each evaluation under this paragraph available to the public in a timely fashion and may establish requirements for States and other entities participating in the testing of models under this section to collect and report information that the Secretary determines is necessary to monitor and evaluate such models.`(c) Expansion of Models (Phase II)- Taking into account the evaluation under subsection (b)(4), the Secretary may, through rulemaking, expand (including implementation on a nationwide basis) the duration and the scope of a model that is being tested under subsection (b) or a demonstration project under section 1866C, to the extent determined appropriate by the Secretary, if-- `(1) the Secretary determines that such expansion is expected to-- `(A) reduce spending under applicable title without reducing the quality of care; or`(B) improve the quality of care and reduce spending; and`(2) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce program spending under applicable titles.`(d) Implementation- `(1) WAIVER AUTHORITY- The Secretary may waive such requirements of titles XI and XVIII and of sections 1902(a)(1), 1902(a)(13), and 1903(m)(2)(A)(iii) as may be necessary solely for purposes of carrying out this section with respect to testing models described in subsection (b).`(2) LIMITATIONS ON REVIEW- There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of-- `(A) the selection of models for testing or expansion under this section;`(B) the selection of organizations, sites, or participants to test those models selected;`(C) the elements, parameters, scope, and duration of such models for testing or dissemination;`(D) determinations regarding budget neutrality under subsection (b)(3);`(E) the termination or modification of the design and implementation of a model under subsection (b)(3)(B); and`(F) determinations about expansion of the duration and scope of a model under subsection (c), including the determination that a model is not expected to meet criteria described in paragraph (1) or (2) of such subsection.`(3) ADMINISTRATION- Chapter 35 of title 44, United States Code, shall not apply to the testing and evaluation of models or expansion of such models under this section.`(e) Application to CHIP- The Center may carry out activities under this section with respect to title XXI in the same manner as provided under this section with respect to the program under the applicable titles.`(f) Funding- `(1) IN GENERAL- There are appropriated, from amounts in the Treasury not otherwise appropriated-- `(A) $5,000,000 for the design, implementation, and evaluation of models under subsection (b) for fiscal year 2010;`(B) $10,000,000,000 for the activities initiated under this section for the period of fiscal years 2011 through 2019; and`(C) the amount described in subparagraph (B) for the activities initiated under this section for each subsequent 10-year fiscal period (beginning with the 10-year fiscal period beginning with fiscal year 2020).Amounts appropriated under the preceding sentence shall remain available until expended. `(2) USE OF CERTAIN FUNDS- Out of amounts appropriated under subparagraphs (B) and (C) of paragraph (1), not less than $25,000,000 shall be made available each such fiscal year to design, implement, and evaluate models under subsection (b).`(g) Report to Congress- Beginning in 2012, and not less than once every other year thereafter, the Secretary shall submit to Congress a report on activities under this section. Each such report shall describe the models tested under subsection (b), including the number of individuals described in subsection (a)(4)(A)(i) and of individuals described in subsection (a)(4)(A)(ii) participating in such models and payments made under applicable titles for services on behalf of such individuals, any models chosen for expansion under subsection (c), and the results from evaluations under subsection (b)(4). In addition, each such report shall provide such recommendations as the Secretary determines are appropriate for legislative action to facilitate the development and expansion of successful payment models.'.(b) Medicaid Conforming Amendment- Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as amended by section 8002(b), is amended-- (1) in paragraph (81), by striking `and' at the end 2) in paragraph (82), by striking the period at the end and inserting `; and'; and(3) by inserting after paragraph (82) the following new paragraph:`(83) provide for implementation of the payment models specified by the Secretary under section 1115A(c) for implementation on a nationwide basis unless the State demonstrates to the satisfaction of the Secretary that implementation would not be administratively feasible or appropriate to the health care delivery system of the State.'.(c) Revisions to Health Care Quality Demonstration Program- Subsections (b) and (f) of section 1866C of the Social Security Act (42 U.S.C. 1395cc-3) are amended by striking `5-year' each place it appears.
SEC. 3022. MEDICARE SHARED SAVINGS PROGRAM.[edit]
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is amended by adding at the end the following new section:
`SHARED SAVINGS PROGRAM`Sec. 1899. (a) Establishment- `(1) IN GENERAL- Not later than January 1, 2012, the Secretary shall establish a shared savings program (in this section referred to as the `program') that promotes accountability for a patient population and coordinates items and services under parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery. Under such program-- `(A) groups of providers of services and suppliers meeting criteria specified by the Secretary may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization (referred to in this section as an `ACO'); and`(B) ACOs that meet quality performance standards established by the Secretary are eligible to receive payments for shared savings under subsection (d)(2).`(b) Eligible ACOs- `(1) IN GENERAL- Subject to the succeeding provisions of this subsection, as determined appropriate by the Secretary, the following groups of providers of services and suppliers which have established a mechanism for shared governance are eligible to participate as ACOs under the program under this section: `(A) ACO professionals in group practice arrangements.`(B) Networks of individual practices of ACO professionals.`(C) Partnerships or joint venture arrangements between hospitals and ACO professionals.`(D) Hospitals employing ACO professionals.`(E) Such other groups of providers of services and suppliers as the Secretary determines appropriate.`(2) REQUIREMENTS- An ACO shall meet the following requirements: `(A) The ACO shall be willing to become accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it.`(B) The ACO shall enter into an agreement with the Secretary to participate in the program for not less than a 3-year period (referred to in this section as the `agreement period').`(C) The ACO shall have a formal legal structure that would allow the organization to receive and distribute payments for shared savings under subsection (d)(2) to participating providers of services and suppliers.`(D) The ACO shall include primary care ACO professionals that are sufficient for the number of Medicare fee-for-service beneficiaries assigned to the ACO under subsection (c). At a minimum, the ACO shall have at least 5,000 such beneficiaries assigned to it under subsection (c) in order to be eligible to participate in the ACO program.`(E) The ACO shall provide the Secretary with such information regarding ACO professionals participating in the ACO as the Secretary determines necessary to support the assignment of Medicare fee-for-service beneficiaries to an ACO, the implementation of quality and other reporting requirements under paragraph (3), and the determination of payments for shared savings under subsection (d)(2).`(F) The ACO shall have in place a leadership and management structure that includes clinical and administrative systems.`(G) The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.`(H) The ACO shall demonstrate to the Secretary that it meets patient-centeredness criteria specified by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans.`(3) QUALITY AND OTHER REPORTING REQUIREMENTS- `(A) IN GENERAL- The Secretary shall determine appropriate measures to assess the quality of care furnished by the ACO, such as measures of-- `(i) clinical processes and outcomes;`(ii) patient and, where practicable, caregiver experience of care; and`(iii) utilization (such as rates of hospital admissions for ambulatory care sensitive conditions).`(B) REPORTING REQUIREMENTS- An ACO shall submit data in a form and manner specified by the Secretary on measures the Secretary determines necessary for the ACO to report in order to evaluate the quality of care furnished by the ACO. Such data may include care transitions across health care settings, including hospital discharge planning and post-hospital discharge follow-up by ACO professionals, as the Secretary determines appropriate.`(C) QUALITY PERFORMANCE STANDARDS- The Secretary shall establish quality performance standards to assess the quality of care furnished by ACOs. The Secretary shall seek to improve the quality of care furnished by ACOs over time by specifying higher standards, new measures, or both for purposes of assessing such quality of care.`(D) OTHER REPORTING REQUIREMENTS- The Secretary may, as the Secretary determines appropriate, incorporate reporting requirements and incentive payments related to the physician quality reporting initiative (PQRI) under section 1848, including such requirements and such payments related to electronic prescribing, electronic health records, and other similar initiatives under section 1848, and may use alternative criteria than would otherwise apply under such section for determining whether to make such payments. The incentive payments described in the preceding sentence shall not be taken into consideration when calculating any payments otherwise made under subsection (d).`(4) NO DUPLICATION IN PARTICIPATION IN SHARED SAVINGS PROGRAMS- A provider of services or supplier that participates in any of the following shall not be eligible to participate in an ACO under this section: `(A) A model tested or expanded under section 1115A that involves shared savings under this title, or any other program or demonstration project that involves such shared savings.`(B) The independence at home medical practice pilot program under section 1866E.`(c) Assignment of Medicare Fee-for-service Beneficiaries to ACOs- The Secretary shall determine an appropriate method to assign Medicare fee-for-service beneficiaries to an ACO based on their utilization of primary care services provided under this title by an ACO professional described in subsection (h)(1)(A).`(d) Payments and Treatment of Savings- `(1) PAYMENTS- `(A) IN GENERAL- Under the program, subject to paragraph (3), payments shall continue to be made to providers of services and suppliers participating in an ACO under the original Medicare fee-for-service program under parts A and B in the same manner as they would otherwise be made except that a participating ACO is eligible to receive payment for shared savings under paragraph (2) if-- `(i) the ACO meets quality performance standards established by the Secretary under subsection (b)(3); and`(ii) the ACO meets the requirement under subparagraph (B)(i).`(B) SAVINGS REQUIREMENT AND BENCHMARK- `(i) DETERMINING SAVINGS- In each year of the agreement period, an ACO shall be eligible to receive payment for shared savings under paragraph (2) only if the estimated average per capita Medicare expenditures under the ACO for Medicare fee-for-service beneficiaries for parts A and B services, adjusted for beneficiary characteristics, is at least the percent specified by the Secretary below the applicable benchmark under clause (ii). The Secretary shall determine the appropriate percent described in the preceding sentence to account for normal variation in expenditures under this title, based upon the number of Medicare fee-for-service beneficiaries assigned to an ACO.`(ii) ESTABLISH AND UPDATE BENCHMARK- The Secretary shall estimate a benchmark for each agreement period for each ACO using the most recent available 3 years of per-beneficiary expenditures for parts A and B services for Medicare fee-for-service beneficiaries assigned to the ACO. Such benchmark shall be adjusted for beneficiary characteristics and such other factors as the Secretary determines appropriate and updated by the projected absolute amount of growth in national per capita expenditures for parts A and B services under the original Medicare fee-for-service program, as estimated by the Secretary. Such benchmark shall be reset at the start of each agreement period.`(2) PAYMENTS FOR SHARED SAVINGS- Subject to performance with respect to the quality performance standards established by the Secretary under subsection (b)(3), if an ACO meets the requirements under paragraph (1), a percent (as determined appropriate by the Secretary) of the difference between such estimated average per capita Medicare expenditures in a year, adjusted for beneficiary characteristics, under the ACO and such benchmark for the ACO may be paid to the ACO as shared savings and the remainder of such difference shall be retained by the program under this title. The Secretary shall establish limits on the total amount of shared savings that may be paid to an ACO under this paragraph.`(3) MONITORING AVOIDANCE OF AT-RISK PATIENTS- If the Secretary determines that an ACO has taken steps to avoid patients at risk in order to reduce the likelihood of increasing costs to the ACO the Secretary may impose an appropriate sanction on the ACO, including termination from the program.`(4) TERMINATION- The Secretary may terminate an agreement with an ACO if it does not meet the quality performance standards established by the Secretary under subsection (b)(3).`(e) Administration- Chapter 35 of title 44, United States Code, shall not apply to the program.`(f) Waiver Authority- The Secretary may waive such requirements of sections 1128A and 1128B and title XVIII of this Act as may be necessary to carry out the provisions of this section.`(g) Limitations on Review- There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of-- `(1) the specification of criteria under subsection (a)(1)(B);`(2) the assessment of the quality of care furnished by an ACO and the establishment of performance standards under subsection (b)(3);`(3) the assignment of Medicare fee-for-service beneficiaries to an ACO under subsection (c);`(4) the determination of whether an ACO is eligible for shared savings under subsection (d)(2) and the amount of such shared savings, including the determination of the estimated average per capita Medicare expenditures under the ACO for Medicare fee-for-service beneficiaries assigned to the ACO and the average benchmark for the ACO under subsection (d)(1)(B);`(5) the percent of shared savings specified by the Secretary under subsection (d)(2) and any limit on the total amount of shared savings established by the Secretary under such subsection; and`(6) the termination of an ACO under subsection (d)(4).`(h) Definitions- In this section: `(1) ACO PROFESSIONAL- The term `ACO professional' means-- `(A) a physician (as defined in section 1861(r)(1)); and`(B) a practitioner described in section 1842(b)(18)(C)(i).`(2) HOSPITAL- The term `hospital' means a subsection (d) hospital (as defined in section 1886(d)(1)(B)).`(3) MEDICARE FEE-FOR-SERVICE BENEFICIARY- The term `Medicare fee-for-service beneficiary' means an individual who is enrolled in the original Medicare fee-for-service program under parts A and B and is not enrolled in an MA plan under part C, an eligible organization under section 1876, or a PACE program under section 1894.'.
SEC. 3023. NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING.[edit]
Title XVIII of the Social Security Act, as amended by section 3021, is amended by inserting after section 1886C the following new section:
NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING`Sec. 1866D. (a) Implementation- `(1) IN GENERAL- The Secretary shall establish a pilot program for integrated care during an episode of care provided to an applicable beneficiary around a hospitalization in order to improve the coordination, quality, and efficiency of health care services under this title.`(2) DEFINITIONS- In this section: `(A) APPLICABLE BENEFICIARY- The term `applicable beneficiary' means an individual who-- `(i) is entitled to, or enrolled for, benefits under part A and enrolled for benefits under part B of such title, but not enrolled under part C or a PACE program under section 1894; and`(ii) is admitted to a hospital for an applicable condition.`(B) APPLICABLE CONDITION- The term `applicable condition' means 1 or more of 8 conditions selected by the Secretary. In selecting conditions under the preceding sentence, the Secretary shall take into consideration the following factors: `(i) Whether the conditions selected include a mix of chronic and acute conditions.`(ii) Whether the conditions selected include a mix of surgical and medical conditions.`(iii) Whether a condition is one for which there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished while reducing total expenditures under this title.`(iv) Whether a condition has significant variation in-- `(I) the number of readmissions; and`(II) the amount of expenditures for post-acute care spending under this title.`(v) Whether a condition is high-volume and has high post-acute care expenditures under this title.`(vi) Which conditions the Secretary determines are most amenable to bundling across the spectrum of care given practice patterns under this title.`(C) APPLICABLE SERVICES- The term `applicable services' means the following: `(i) Acute care inpatient services.`(ii) Physicians' services delivered in and outside of an acute care hospital setting.`(iii) Outpatient hospital services, including emergency department services.`(iv) Post-acute care services, including home health services, skilled nursing services, inpatient rehabilitation services, and inpatient hospital services furnished by a long-term care hospital.`(v) Other services the Secretary determines appropriate.`(D) EPISODE OF CARE- `(i) IN GENERAL- Subject to clause (ii), the term `episode of care' means, with respect to an applicable condition and an applicable beneficiary, the period that includes-- `(I) the 3 days prior to the admission of the applicable beneficiary to a hospital for the applicable condition;`(II) the length of stay of the applicable beneficiary in such hospital; and`(III) the 30 days following the discharge of the applicable beneficiary from such hospital.`(ii) ESTABLISHMENT OF PERIOD BY THE SECRETARY- The Secretary, as appropriate, may establish a period (other than the period described in clause (i)) for an episode of care under the pilot program.`(E) Physicians' SERVICES- The term `physicians' services' has the meaning given such term in section 1861(q).`(F) PILOT PROGRAM- The term `pilot program' means the pilot program under this section.`(G) PROVIDER OF SERVICES- The term `provider of services' has the meaning given such term in section 1861(u).`(H) READMISSION- The term `readmission' has the meaning given such term in section 1886(q)(5)(E).`(I) SUPPLIER- The term `supplier' has the meaning given such term in section 1861(d).`(3) DEADLINE FOR IMPLEMENTATION- The Secretary shall establish the pilot program not later than January 1, 2013.`(b) Developmental Phase- `(1) DETERMINATION OF PATIENT ASSESSMENT INSTRUMENT- The Secretary shall determine which patient assessment instrument (such as the Continuity Assessment Record and Evaluation (CARE) tool) shall be used under the pilot program to evaluate the applicable condition of an applicable beneficiary for purposes of determining the most clinically appropriate site for the provision of post-acute care to the applicable beneficiary.`(2) DEVELOPMENT OF QUALITY MEASURES FOR AN EPISODE OF CARE AND FOR POST-ACUTE CARE- `(A) IN GENERAL- The Secretary, in consultation with the Agency for Healthcare Research and Quality and the entity with a contract under section 1890(a) of the Social Security Act, shall develop quality measures for use in the pilot program-- `(i) for episodes of care; and`(ii) for post-acute care.`(B) SITE-NEUTRAL POST-ACUTE CARE QUALITY MEASURES- Any quality measures developed under subparagraph (A)(ii) shall be site-neutral.`(C) COORDINATION WITH QUALITY MEASURE DEVELOPMENT AND ENDORSEMENT PROCEDURES- The Secretary shall ensure that the development of quality measures under subparagraph (A) is done in a manner that is consistent with the measures developed and endorsed under section 1890 and 1890A that are applicable to all post-acute care settings.`(c) Details- `(1) DURATION- `(A) IN GENERAL- Subject to subparagraph (B), the pilot program shall be conducted for a period of 5 years.`(B) EXTENSION- The Secretary may extend the duration of the pilot program for providers of services and suppliers participating in the pilot program as of the day before the end of the 5-year period described in subparagraph (A), for a period determined appropriate by the Secretary, if the Secretary determines that such extension will result in improving or not reducing the quality of patient care and reducing spending under this title.`(2) PARTICIPATING PROVIDERS OF SERVICES AND SUPPLIERS- `(A) IN GENERAL- An entity comprised of providers of services and suppliers, including a hospital, a physician group, a skilled nursing facility, and a home health agency, who are otherwise participating under this title, may submit an application to the Secretary to provide applicable services to applicable individuals under this section.`(B) REQUIREMENTS- The Secretary shall develop requirements for entities to participate in the pilot program under this section. Such requirements shall ensure that applicable beneficiaries have an adequate choice of providers of services and suppliers under the pilot program.`(3) PAYMENT METHODOLOGY- `(A) IN GENERAL- `(i) ESTABLISHMENT OF PAYMENT METHODS- The Secretary shall develop payment methods for the pilot program for entities participating in the pilot program. Such payment methods may include bundled payments and bids from entities for episodes of care. The Secretary shall make payments to the entity for services covered under this section.`(ii) NO ADDITIONAL PROGRAM EXPENDITURES- Payments under this section for applicable items and services under this title (including payment for services described in subparagraph (B)) for applicable beneficiaries for a year shall be established in a manner that does not result in spending more for such entity for such beneficiaries than would otherwise be expended for such entity for such beneficiaries for such year if the pilot program were not implemented, as estimated by the Secretary.`(B) INCLUSION OF CERTAIN SERVICES- A payment methodology tested under the pilot program shall include payment for the furnishing of applicable services and other appropriate services, such as care coordination, medication reconciliation, discharge planning, transitional care services, and other patient-centered activities as determined appropriate by the Secretary.`(C) BUNDLED PAYMENTS- `(i) IN GENERAL- A bundled payment under the pilot program shall-- `(I) be comprehensive, covering the costs of applicable services and other appropriate services furnished to an individual during an episode of care (as determined by the Secretary); and`(II) be made to the entity which is participating in the pilot program.`(ii) REQUIREMENT FOR PROVISION OF APPLICABLE SERVICES AND OTHER APPROPRIATE SERVICES- Applicable services and other appropriate services for which payment is made under this subparagraph shall be furnished or directed by the entity which is participating in the pilot program.`(D) PAYMENT FOR POST-ACUTE CARE SERVICES AFTER THE EPISODE OF CARE- The Secretary shall establish procedures, in the case where an applicable beneficiary requires continued post-acute care services after the last day of the episode of care, under which payment for such services shall be made.`(4) QUALITY MEASURES- `(A) IN GENERAL- The Secretary shall establish quality measures (including quality measures of process, outcome, and structure) related to care provided by entities participating in the pilot program. Quality measures established under the preceding sentence shall include measures of the following: `(i) Functional status improvement.`(ii) Reducing rates of avoidable hospital readmissions.`(iii) Rates of discharge to the community.`(iv) Rates of admission to an emergency room after a hospitalization.`(v) Incidence of health care acquired infections.`(vi) Efficiency measures.`(vii) Measures of patient-centeredness of care.`(viii) Measures of patient perception of care.`(ix) Other measures, including measures of patient outcomes, determined appropriate by the Secretary.`(B) REPORTING ON QUALITY MEASURES- `(i) IN GENERAL- A entity shall submit data to the Secretary on quality measures established under subparagraph (A) during each year of the pilot program (in a form and manner, subject to clause (iii), specified by the Secretary
. . .
and on and on and on
It goes on for another 12 pages or so, but what's the point when someone can just make up stuff out of thin air?
Pretzel_Warrior
(8,361 posts)dkf needs to be constantly flooded with actual facts.
Abq_Sarah
(2,883 posts)The fed has created a mandatory market. People must purchase a private policy from the insurance industry or be fined/taxed by the government. Insurance policies now must offer more "free" stuff to consumers. More people are going to be taking advantage of the so-called free services which drive up costs to insurers who then turn around and pass it to consumers/taxpayers.
If the fed mandated that everyone in the country had to purchase the services offered by my company, of course my profits would increase. Just by sheer volume, profits are going to skyrocket IF and only IF, everyone signs up as mandated by the government.
lumberjack_jeff
(33,224 posts)Your profits would increase if the federal government hadn't legally capped your profits.
Health care was never anything other than mandatory. If you don't purchase it, you die.
It is a failure of both logic and humanity to say that the uninsured and those with preexisting conditions are making the world suck for you through their newfound access to health care. You were paying for their care all along, but in an inefficient, ineffective and expensive way
solarhydrocan
(551 posts)here's the 5yr on UnitedHealth Group Incorporated (UNH)-supposedly the largest
Link for multiple charts on AET AFL AIZ CI CNC CFIN HNT HUM SIE TMK UNM WLP
http://finance.yahoo.com/quotes/AET+AFL+AIZ+CI+CNC+CFIN+HNT+HUM+TMK+UNM+WLP/view/dv
Talk about performance! Those CEO's are gonna get a heck of a bonus! In 1 hour they can spend the premiums of 5 fast food workers for a year and not break a sweat
CreekDog
(46,192 posts)considerably less than that, in fact.
especially now that profits have been limited by law.
Yo_Mama
(8,303 posts)Try checking the premiums for a person in their 50 or 60s. You can't translate insurance costs for an individual in their 20s to average costs for the population!
In my neck of the woods, Silver premiums for a family with adults in their early 50s and two kids run around $1,500 monthly.
The lowest premium for a couple aged 58 and 60 is $1,739.17 ($20,870 annually) a month with a $6,000 deductible. Thus if the couple is not subsidized, they would pay almost $27,000 a year before getting any treatment for a medical condition. Yes, they get free vaccinations, a couple of "wellness" visits and so forth, but when it comes to actually getting treatment, they have to shell out $6,000 before any bills are paid by the insurance company.
those numbers are wildly out of line with themselves actually, but also with the OP.
the couple aged 58 and 60 cost 1739/month
the 2 adults + family in 50s cost 1500/month
so it's cheaper to insure the family with 2 adults in their 50's than just two adults?
your numbers are unreliable.
Yo_Mama
(8,303 posts)Try ValuePenguin - you can't get these numbers from healthcare.gov - they haven't loaded them. They just offer premiums for 27 and 50.
http://valuepenguin.com/
I called an insurance company to check some of the premiums by age, and they confirmed them.
you won't say where? BS if you won't.
Yo_Mama
(8,303 posts)Next you'll ask for my mailing address.
Look it up yourself.
dixiegrrrrl
(60,010 posts)for different ages, for single people, for families, for 1 parent with 1 and with 2 kids.
All you have to do is use tables at the website as I indicated.
Yo_Mama
(8,303 posts)The only two ages it gives you are 27 and 50+. That's not how policies are priced. Those premiums are meant to be a sample to give people an idea of their options.
dixiegrrrrl
(60,010 posts)Got it.
Abq_Sarah
(2,883 posts)Except where they haven't been as evidenced by waivers granted by HHS.
JDPriestly
(57,936 posts)That will be the next focus.
NoOneMan
(4,795 posts)The main problem is they are largely in control of the size of the pie.
lumberjack_jeff
(33,224 posts)Insurers expenses and profits must be taken from the remaining 15%.
Also, since consumers can now compare apples to apples (compare one silver plan to another) they can effectively drive down prices.
It will effectively suppress medical cost inflation.
Response to lumberjack_jeff (Reply #85)
NoOneMan This message was self-deleted by its author.
NoOneMan
(4,795 posts)Its like an invisible divine hand from God
http://en.wikipedia.org/wiki/McCarran%E2%80%93Ferguson_Act
Or alternatively, they will collude like the bastards they were born to be to make sure that fucken pie is so big that all their executives get their own gold plated concord from their ensured cut
lumberjack_jeff
(33,224 posts)Insurers must accept everyone, and their offerings now must offer a consistent set of coverages and conform to 70, 80 or 90% actuarial values. Consumers can now make rational choices.
The only knobs the insurers can tweak to attract market share is to choose a balance between premiums and deductibles within the same actuarial tier, and/or cut margin.
Sedona
(3,769 posts)the costs will be lower across the board because people aren't gong to be going to high cost emergency rooms with acute health problems that could have been solved in lower cost doctors offices before they became acute.
The point is ACA will save EVERYONE money; us, the insurance companies and the government.
The point is...the costs are going to be spread around more equitably.
The point is the insurance companies will now have to spend 80% of premiums on "health care".
The point is to look at the big picture before throwing stones and creating fodder for the RWNJ's.
NoOneMan
(4,795 posts)the costs will be lower across the board because people aren't gong to be going to high cost emergency rooms with acute health problems that could have been solved in lower cost doctors offices before they became acute.
Remember, there are still ingrained mechanisms that promote self-rationing called copays and deductibes, which discourage seeking help in all but the most urgent cases.
It is rather a theory that this will significantly alter costs actually. For another 5 years, the jury is still out
notadmblnd
(23,720 posts)You forgot to add.
And if they don't spend 80% on actual health care for their policy holders, then they have to reimburse the policy holder(s) the difference.
If enough healthy people enroll, then over time I think there will actually be a lowering of premiums for everyone..
leftstreet
(36,109 posts)Employer insurance, Medicare, Medicaid, etc
Most people are already 'enrolled' but premiums went up, not down
notadmblnd
(23,720 posts)But still, if 80-85% of what insurers take in is not used by the insurance companies for actual health care. The insurance companies are required to refund the money to their policy holders.
So there is no sense in continuing to raise annual premiums on policy holders. Insurers can no longer claim that their costs increasing if they are not. They now have to prove that they spent 80-85% of what they took in on claims. If they don't they have to give it back.
There are people here who can attest to the fact that they received refunds last year from their health insurance providers.
I just don't understand how people can't see the ACA working and working well.
treestar
(82,383 posts)without money? So what? They are getting it for health care spending.
woo me with science
(32,139 posts)The subsidies hide the fact that we are still the losers, by design. Costs are still outrageous, and the subsidies that pay them are obtained from our tax dollars. Tax money pouring into the pockets of bloodsucking corporate middlemen is money that is not poured into schools, roads, and community centers.
The ironically named "Affordable Care Act" has entrenched the corporate middlemen into the system and guaranteed their profits, while ignoring the actual problem of skyrocketing costs and insurance company profiteering.
It was designed as a corporate gift. It remains a corporate gift.
JDPriestly
(57,936 posts)possibly pay.
Do you buy your own insurance? I used to. I bought the cheapest policy and it cost me over $300 per month. That's just how much it costs. People who get subsidies will be doing much better than they would have before ACA.
dixiegrrrrl
(60,010 posts)until you get the subsidy?
and is the subsidy a refund or just a tax "credit"?
I am also wondering about deductibles, co-pays and out of pocket expenses.
lumberjack_jeff
(33,224 posts)Essentially, the government gives you your ACA tax credit each month rather than at the end of the year.
dkf
(37,305 posts)I've heard the potential problem is if you estimate income and get a subsidy, then when you do your taxes you may not have been entitled. Now there is a risk to making more $!
CreekDog
(46,192 posts)thank you for pointing that out.
oh, wait, you didn't.
dkf
(37,305 posts)brush
(53,791 posts)The insurance companies make way more now on the old system than they will under the ACA.
We just don't see that because the employers pick up a big part of the actual costs that out healthcare deductions from our paychecks don't come close to covering.
Insurance companies are insured (so to speak) of making money under the ACA but less than they were making before.
Large corporate employers should actually be embracing Obamacare because it has the potential to lower their contributions to their workers healthcare, therefore making their products less costly to produce and more competitive in the marketplace . . . if they participate that is and not start cutting peoples' hours so they don't qualify for healthcare benefits.
progressoid
(49,991 posts)Jack around with the costs until you get your 15-20% profit.
stevenleser
(32,886 posts)progressoid
(49,991 posts)Rather than paying the actual cost of health care, we get to pay that plus the insurance companies cost of their "service" plus an additional 20% for profit.
Hooray!
Xithras
(16,191 posts)It's just like the EIC, except that you get to estimate it in advance and apply it to your health insurance coverage. Using your selected exchange, you'll put in all of your financial information and estimate what your total income for the coming year will be. Based on that, your subsidy will be calculated. You will then get to decide how much of the subsidy you want to apply to your healthcare premiums. The government will then send the portion you chose (100% divided into 12 payments, in most cases) directly to the insurance company.
The only real "gotcha" is that you'll have to be fairly accurate when estimating your income. If you complete your taxes at the end of the year and discover that you've made more money than you estimated, your actual subsidy will be reduced and you will have to immediately repay the IRS. You are, in essence, "borrowing" next years tax credit in advance, and will have to repay the difference if you "borrow" more money than your final credit actually covers. This won't be a problem for most working people with steady jobs and predictable income, but low income workers with unsteady part time jobs will have to be incredibly careful to project their income as accurately as possible. Additionally, people going from part time work to fulltime work, with an assumed spike in pay, will need to remember to immediately report that to the exchange and have their subsidies adjusted, or they could end up owing the IRS thousands of dollars in repayments when April rolls around.
On the flipside, if your pay goes down and your subsidy has INCREASED beyond what you had projected at the beginning of the year, you'll get the difference added to your tax refund.
HERVEPA
(6,107 posts)What's the point?
NoOneMan
(4,795 posts)It is useful to see what portion of a workers income, on average, would go to deliver necessities (that may only be necessary to that particular social and economic structure). While in this specific case some of those costs are paid by "others" (subsidies), but as a whole, America is certainly committed to spending a large portion of their labor on the health care industry. And this portion of labor needed to ensure everyone can live, breath, and pursue happiness is certainly growing, such that we may no longer have free time left to pursue happiness if we wish to afford to live:
FarCenter
(19,429 posts)So roughly speaking, on average, 18% of an American worker's income should be going towards healthcare in Medicare taxes, other taxes, insurance premiums, and direct expenditures.
NoOneMan
(4,795 posts)So unless wages are going to double or housing and food are going to plummet, the US is in for a world of hurt.
FarCenter
(19,429 posts)If housing plummets, you get another mortgage crisis, with people walking away from underwater mortgages.
My expectation is that hospitals merge, take over clinics, testing labs, etc., and then merge with the insurance companies.
They will then be able to reduce employment in healthcare and drive down costs, along with severely restricting the more expensive healthcare options after they achieve regional monopolies.
magical thyme
(14,881 posts)The labs merge with each other into lab chains associated with a centralized reference lab. Our reference lab is part of a large hospital. Other large hospital systems already have their own labs. In the chains I'm familiar with, small satellite labs operate inside the hospital running routine tests. In my particular lab, we send non-routine tests down to our reference lab headquarters about an hour and a half to hour south twice daily on weekdays and on weekend mornings, or to Mayo clinic for very specialized tests. For micro, we plate the specs and incubate them onsite and then pack them up to go to the reference lab for ID and susceptibility testing. For bloodbanking, we do type/screen and cross-matches, but if the antibody screen turns up positive, we send the spec down to the reference lab to ID the antibodies. For specialty chemistries, we'll draw off the serum after completing the routine CMP spec and send out just the serum. We do routine CBCs and manual smears, but if certain criteria are met, we'll make extra smears to send the pathologist at the reference lab. So we get the routine and ED stuff and they get the interesting stuff.
Why would insurance companies merge with hospitals? They serve no real purpose.
FarCenter
(19,429 posts)If the hospitals merge into a couple of networks, and then each merge with a dominant insurance company, you do for health care what Walmart and Target do for retailing or what Lowes and Home Depot do for home improvement.
Note that CVS and Caremark merged to become both the largest pharmacy chain and one of the largest Medicare Part D insurance providers and pharmacy benefits managers.
magical thyme
(14,881 posts)Private practice doctors and clinics already refer patients to hospitals and send specs to hospital labs for routine testing.
And at least where I live, the local hospitals have reputations as good or not so good, and a lot of people make their choices that way.
Insurance is an awfully expensive way for hospitals to gain referrals. They don't provide *any* added value from the hospital's perspective, other than paying the bills, and they are an awfully expensive accounting service.
notadmblnd
(23,720 posts)If your health insurance premiums exceed 9 or 9.5 percent of your income, you will get a subsidy.
The other thing I want to point out is- if the insurance companies do not actually pay 80 or 85% of the premiums they take in on health care for their policy holders, the insurance companies have to reimburse the policy holders.
So for example, if BCBS takes in 100 dollars and only pays out 70 dollars, the difference 80-70=10, ten dollars will be refunded.
I think if enough healthy people enroll, we could actually see the brakes put on seemingly arbitrary annual increases in health care premiums that have become the norm the last few decades. I think we could health insurance costs actually decreasing in the coming years.
FarCenter
(19,429 posts)It doesn't include what you pay in Medicare taxes, or in direct medical expenses.
And the subsidies don't come from thin air -- other taxpayers will pay more to provide money for the subsidies.
notadmblnd
(23,720 posts)are now no cost. This will more than work if healthy people buy into this.
So far, there have been no tax increases to cover the cost of the subsidies and keep in mind that this is for people that do not have any medical insurance or those that currently purchase their own and want to check out the prices on the exchange.
And although, it has been delayed a year, there is an employer mandate, so if an employer has more than 50 employees they will be required to provide health care coverage to their employees just as many companies currently do.
Yes, subsidies cost money and most people's employers currently provide those subsidies as one of the benefits of their employment.
I do think that there are still more healthy people than sick people, so no, I don't see that the sky is falling anytime soon over the ACA and I think that those who do proclaim it is and just generally spread gloom and doom in regards to the ACA, should maybe just hide and watch for a little while.
NoOneMan
(4,795 posts)The money has to come from somewhere. Its is not magic fairy money. If the costs as a percent of GDP approach 30%, do you think that isn't going to impact everyone and the economy in a significant way just because you've figured out some way to spread the costs?
Yo_Mama
(8,303 posts)I looked up premiums (the correct ones, not on healthcare.gov) for a couple aged 58 and 60:
The monthly SUBSIDY where I live for that 58/60 year old couple with a 60K income is $1,341 a month, or $16,092 a year. But if that same couple made $63,000 a year, they would have to pay the entire cost of the premium, which is around $1,800 a month. When you figure in taxes, it costs them even more to earn that extra $3,000 a year. Compared to earning 60K, they have to earn close to 90K before they start keeping any extra money.
People who are not covered by employer insurance will be dropping their incomes like mad, because this is a negative income tax. If you make more than 400% of poverty level, you end up with less money. So there is also the cost of the lower income taxes to add to the premiums.
Mind you, the insurance they get isn't particularly good - they would have to cover $6,000 in deductibles before it even kicks in - but the cost of the premiums is what will drive them to drop their incomes.
Mass
(27,315 posts)Prices look correct. They are probably not higher than premiums with similar coverage this year.
This said, a lot of people had crappy plans that covered nothing. Those are the ones the GOP is whining about. They want people to buy plans that cover nothing.
Lex
(34,108 posts)dixiegrrrrl
(60,010 posts)CreekDog
(46,192 posts)if you think it's pure profit, i think you need to brush up on the law.
dixiegrrrrl
(60,010 posts)and thought others might be interested.
There is plenty about the law I am learning about.
For instance, I just learned this:
Individuals are exempt from the individual mandate if their health insurance exceeds 8% of their household income.
Now I am trying to figure out if that means gross or net income.
Do you know?
CreekDog
(46,192 posts)or adjusted.
Blue_In_AK
(46,436 posts)Alaska and Wyoming, from what I've read, have the highest premiums. I don't know about Wyoming, but Alaska's governor has refused the Medicaid expansion, even though just this morning I see the Chamber of Commerce is urging him to reverse his extreme ideological stand. If he does, hopefully we'll have some competition.
http://www.adn.com/2013/10/24/3139519/state-chamber-backs-medicaid-expansion.html
bravenak
(34,648 posts)I hope that idiot Parnell expands Medicaid. I loath him with every fiber of my being.
Blue_In_AK
(46,436 posts)Were you at the rally yesterday afternoon?
bravenak
(34,648 posts)Got the pneumonia again this year. Can't stop coughing. Been having strange medical problems, it weird, yo. Where was it , what happened? Was it in anchorage? Maybe my and the child can come to the next one? I live right near Gambell Carr's so I'm centrally located.
Oh I just looked it up. Was that by midtown walmart?
Blue_In_AK
(46,436 posts)It was to protest him seeking attorney's fees from Vic Fischer and Bella Hammond, among others, who lost their suit against the state and Pebble Partnership.
Here's a little write-up in the ADN.
http://www.adn.com/2013/10/23/3139470/rally-targets-parnell-administration.html
I mean, seriously, what kind of an asshole would want to threaten the 80-year-old widow of one of Alaska's greatest governors with losing her home ... Or one of the writers of Alaska's constitution, for that matter. My contempt for Sean Parnell knows no bounds. He almost makes me miss Sarah.
bravenak
(34,648 posts)I sometimes feel like we live in bigger Texas.
He should be ashamed of himself find trying collect attorneys fees, but he has no human emotions and therefore no shame.
I got a letter from child support through the governors office one time telling me they would be charging me and my husband child support for our youngest daughter, that they would collect from his check take fees and pay to me. WTF?!?! I have never in my life heard of anything like this, we're married and I've never left him or filed for child support at all. How do you charge a man money to take care of a child that he's fully supporting that lives with him and her mother? Republican big government.
I finally got them to stop charging him ( he refused to pay, duh) but they still send letters from time to time announcing that they are going to start collecting child support for my kids again. I always call his office and yell on his voicemail.
That's why I hate Sean Parnell. I blame him personally for stressing me out and making it so hard to stop child support you never filed for. He's a money grubbing bastard and I wouldn't be surprised if he's been lining his pockets with Oil, and Mining bribes.
Blue_In_AK
(46,436 posts)still working for them even from the Governor's office.
When people here go on about Scott Walker, Rick Scott, etc., I always think, "Those governors got nothing on Sean."
bravenak
(34,648 posts)He's unmatched. Absolutely.
OregonBlue
(7,754 posts)NoOneMan
(4,795 posts)After all the subsidy talk and yada yada, it most certainly is crazy what portion of your labor goes just to promote "health" (assuming that such expenses actually improve health outcomes significantly for all). Its interesting how far we've progressed, such that we've created a society whose conditions create sickness and disease, in which we must exacerbate such conditions (such as stressful work) just to combat its very ills. At some point you may reach the point of diminishing returns.
16 hour work days to pay for the cancer caused by the stress and industrial pollutants from the 15 hour workday?
handmade34
(22,756 posts)Happyhippychick
(8,379 posts)Warren Stupidity
(48,181 posts)In addition there are co-pays and other out of pocket expenses. We have the planet's most expensive health care system, which would be sort of ok if was also the planet's best healthcare system, but it isn't, it is mediocre. The ACA just provides access to that crappy but expensive system.
Sheepshank
(12,504 posts)I have an HSA and my employer pops another $3500 into my account annually. My out of pocket max is $6000 so I could potentially be on the hook for $2500 out of pocket. Luckily we have a fairly healthy troop and have only hit the out of pocket max once.
so currently my Insurance company is making a min of $12K and a portentially $18K a year, just from me.
I don't think they will be reaping these kinds of monies under ACA.
astonamous
(1,336 posts)My husband is a federal employee and retired military. His monthly premium costs about $400 and we still have copays and other out of pocket expenses.
woo me with science
(32,139 posts)Then, the argument shifted to bragging that costs are not *increasing* as rapidly as they once were.
Now, we are told that the subsidies make everything all better. But we pay the subsidies, too, with our tax dollars. Every tax dollar that is funneled to bloodsucking corporate insurance company middlemen is a tax dollar that is not going to schools, roads, and community services.
America is now a tightly bound prisoner of a corporate government. Every area of policy shows it. Health insurance, education, the surveillance state, the police state....
For a few months there this country seemed to have a growing awareness that the problem is not partisan and that we need to unite as the 99 percent against what they are doing to us. We were united against NSA spying. We fought back against more war in Syria.
We have to reject the constant, deliberate limitation of choices to the corporate shit sandwiches put before us. We need to be pushing, loudly, for actual solutions, not just the lesser of two evils.
CreekDog
(46,192 posts)that's what you mean, correct?
correct me if i'm wrong, but BC/BS must spend 80-85% of premiums on health care.
so when you say they are going to "get" surely you mean the part that pads their "wallets". and that's limited by law now.
you and I are understanding how the law works, correct? or are you not?
OmahaBlueDog
(10,000 posts)So thy could continue to get decent returns if the markets continue to prosper.
OTOH, and rounding up for simplicity, BC/BS would take in $2,400 in premium per year. Obviously, they'd generally make money charging that over a large base of 27YOs, however, in any individual instance, even the most minimal hospital stay would burn through that $2,400 very quickly.
Also, just because it is not spent on healthcare does not mean it is profit. Insurance companies have overhead.
dixiegrrrrl
(60,010 posts)since, from what I have seen of the table, they are the only insurance company listed.
There are a few other insurance companies listed in some counties in some states, but looks like BC/BS is the main provider.
magical thyme
(14,881 posts)doctors, PAs, pathologists, nurses, cnas, technicians (xray, respiratory, lab, etc.), phlebotomists *provide* healthcare.
Insurance companies bill people and either pay or refuse to pay for their health care.
Big. Difference.
I've yet to see an insurance employee provide one bit of health care.
okaawhatever
(9,462 posts)1. What kind of insurance do you have now
2. What does it cost?
3. What are you currently paying per year in co-pays, unreimbursed, prescription, etc.
3. If you make very little money, why aren't you quoting the bronze or catastrophic plan? They are designed for those who are younger and healthy and want to spend less in premiums.
4. The "cost" of anything includes all expenses. Even for some if their premium goes up, but their out-of-pocket expenses go down they're saving money. Ditto those who are paying lower premiums, but higher out of pocket.
Many have already mentioned the subsidies, but before claiming holy you know what, please put things in context for the reader.
Fumesucker
(45,851 posts)okaawhatever
(9,462 posts)serious questions. The "younger" people have largely been quoted as getting the catastrophic plan. In fact, that is who it was designed for. I also wondered about not getting the bronze plan at that age. I don't know why that is, i'm looking for info to pass on or debunk rwnj's. I'm almost 50 so I won't be looking too much at the lower plans and can't really put myself in the mindset of a twenty something. As a woman, especially if I were young, i'd be looking at a plan that covered birth control since that's about $70 per month. The difference between plans if less than $100 would make sense if it included that benefit.
Fumesucker
(45,851 posts)For one thing they'll lose a day's pay by going to the doctor.
Demo_Chris
(6,234 posts)Or matter. Nor, apparently, do the millions who simply cannot afford even an extra fifty or hundred a month for insurance they will not be able to afford to use. They don't matter either.
LWolf
(46,179 posts)1. Employer provided insurance; they pay most of the premium, I have a hefty deductible and 20% copay. I don't use the insurance for anything but emergencies because my budget doesn't include money for care after paying my part of the premium.
2. About $900 a month, of which, again, my employer pays most.
3. See above.
3. I make too much money for subsidies. I still can't afford care. The economic collapse has left me, with the collapse of the housing market and now 5 years of pay cuts, upside down in a house I can't unload, whose mortgage is now 50% of my net income.
4. I've been to my state's exchange. I could get a lower premium, but it would cost me more because my employer wouldn't pay any of it. That's a net INCREASE in insurance cost before I ever get any care. With those lower premiums, my deductible is 4X higher, and the copay doubles. I'm clearly not going to do this; it puts affording actual care further away than ever. The premium that would give me the same deductible and copay as I've got now, WHICH I CURRENTLY CAN'T AFFORD TO ACTUALLY USE, requires a premium of $1200 a month, $300 more than my employer pays, and much more than my budget will stretch to, considering I'd have to pay the whole thing without my employer.
Suggesting that "the subsidies" make insurance affordable for everyone, let alone actual care, is dishonest.
Pretending that the goal is to have insurance, rather than get actually affordable care, is disingenuous, at best. Insurance is not care, and having it doesn't mean one can afford care. The ACA doesn't make insurance affordable for all, let alone actual health care.
If you can acknowledge that, I'm happy to acknowledge that the ACA will make insurance less costly, if not actually affordable, for some, and that some people might have access to care they can pay for after paying for the insurance.
OmahaBlueDog
(10,000 posts)If so, $193 a month could be a very good price (depending on co-pays, deductibles, yada, yada, yada)
bravenak
(34,648 posts)It does seem like a good price.
OmahaBlueDog
(10,000 posts)..and maternity was EXCLUDED. At that time, basic, uncomplicated childbirth was about $5K -$10K.
We didn't get that coverage until Mrs. OBD and I went to work for larger companies with group plans.
Hoyt
(54,770 posts)There even better if you've ever needed insurance, but had a pre-existing condition (assuming the agent doesn't laugh at you).
Insurance is not cheap. Many people think it's cheaper than it is because they've never paid the full amount (employer picks up a bunch).
Those with low incomes, will pay little or anything under ACA.
dixiegrrrrl
(60,010 posts)one would be except from the mandate to buy.
I am wondering how many younger, healthy people will join, since the program needs them to balance out the older, not as healthy people.
sadly, the younger age group is getting hit hard by college debt, bad job market, ever growing cost of living.
Hoyt
(54,770 posts)zazen
(2,978 posts)Are you in one of those states that rejected Medicaid expansion? NC didn't accept the Medicaid expansion and they did something to restrict an exchange being set up, so the costs here are much higher than they'd be in other states, since there's very little competition.
And a lot of us fall outside subsidies qualification but don't have any new Medicaid. So we won't be insured. About 350k of us, who could keel over and die as far as the GOP is concerned.
dixiegrrrrl
(60,010 posts)For the 22 states that did not cover expansion, people will not face any penalty for not signing up.
But are indeed screwed, as you say.
and Alabama did not join the exchange.
Ironically, our red gov. is a Dr.
<img src=""
alt="Where the States Stand" width="800" border="0"/></a><br />
Via: <a href="http://www.advisory.com/medicaidmap">The Advisory Board Company</a></p>
JaneyVee
(19,877 posts)RedRocco
(454 posts)You still may not qualify. For instance, here in S.C., there is no medicaid eligibility for single, non-disabled, adults.
ecstatic
(32,712 posts)people in states that did not expand Medicaid. It sucks that they still won't be covered though. If SC or any other red state folks take issue with that, vote in a democratic governor.
GeorgeGist
(25,321 posts)Care Act do you not believe?
dixiegrrrrl
(60,010 posts)lsewpershad
(2,620 posts)for the past 40 years and for the first time in all those years I received money back [checks] from the ins company since ACA. This has to be good.
pnwmom
(108,980 posts)on his COBRA, for just one person.
phleshdef
(11,936 posts)The plans are good, the premiums are good and its not for-profit.
BarackTheVote
(938 posts)So $450/m... even with the gold plan, I'll be spending over $100 less. So, sweetness!
Drew Richards
(1,558 posts)solarhydrocan
(551 posts)Time for drones, time for Syria, time for Trans Pacific Partnership, time to bailout the 1%.
But "The Jobs Are Gone". Just like the wind.
NoOneMan
(4,795 posts)SaveAmerica
(5,342 posts)alarimer
(16,245 posts)Some people will get subsidies though.
But, yeah, I think they're still way too high. They're too high because the overhead of insurance companies is something like 25% or more. And the millions raked in by the CEOs.
Incitatus
(5,317 posts)I quick Google search indicates starting wages around $30k, with median about $50k+. I think your county is way below the national average.
dixiegrrrrl
(60,010 posts)I posted the example relative to my county because I know what this county is like.
Glassunion
(10,201 posts)I have had employer health care for nearly 20 years. This year the insurance company dumped all of our existing plans and the company had to shop around for new HC for us.
I used to have a great plan. It was equivalent to a Platinum plan, with 90% coverage with an annual maximum out of pocket of $1,000. It was equal across the board, both men and women of all ages paid the same, smokers paid more.
My annual cost ($42 per week) - $2,184
My annual maximum out of pocket - $1,000
CoPays...
Annual Physical - Free
Std Dr Visit - $20
Specialist - $30
Hospital (inpatient/emergency) - $100
Mental health - $30 (up to 60 visits per year)
Rx Generic - $2
Rx Formulary - $25 (I use this 6 times a year, my inhalers retail for $250)
Rx Non-Formulary - $40 or 30% of retail.
My Current Plan is close to a platinum plan with 80% coverage
My annual cost ($64 per week) - $3,328
My annual maximum out of pocket - $2,500
Annual Physical - Free
Std Dr Visit - 80% after annual deductible ($1,500)
Specialist - 80% after annual deductible ($1,500)
Hospital (inpatient/emergency) - 80% after annual deductible ($1,500)
Mental health - 80% after annual deductible ($1,500)
Rx - 80% after annual deductible ($1,500)
So basically, 2 doctors visits a year (1 is my free physical) plus my inhalers and I'll hit my $1,500 deductible. Then I'll be covered for 80% until I spend another $1,000, then everything is covered 100%.
So basically this year I paid:
$2,184 for the plan
$100 for a trip to the emergency room
$20 for a Dr Visit
$150 for my Rx
Total: $2,454
This coming year the same services will have cost me
$3,328 for the plan
$1,500 for my Rx
$13 for a Dr Visit (assuming I've met my deductible)
$652 for a trip to the emergency room (assuming I've met my deductible)
Total: $5,493
The insurance companies are making out in this.
Good news is that our vision and dental did not budge.
dixiegrrrrl
(60,010 posts)Most of the focus of talk about the law is on who pays how much in premiums.
So far not much conversation on co=pays, deductibles, out of pocket, limitations on service
AND all the plans I have seen are PPO.( Preferred Provider) which means ...what happens when you need care out of your area?
and is your current Dr. covered in the new plan?
Rosa Luxemburg
(28,627 posts)It's actually less expensive than our current policy for family.
Thirties Child
(543 posts)She went into the hospital Tuesday for tests and comfort - she needed so many tests that they felt it would be easier if she was actually in the hospital, and they could do a better job controlling her pain in the hospital. She was to go home tomorrow, but they decided she should stay until sometime next week, her husband says because (1) they want to do more tests and (2) she'll be better off in the hospital than at home.
Can you imagine what would have happened here? They might have kept her overnight, if they'd agreed to hospitalize her at all. I fervently hope that ACA is a step toward single-payer. It's ridiculous how far behind we are.
trumad
(41,692 posts)ScreamingMeemie
(68,918 posts)The premium for a silver plan for my son and I with $40K income, 1800 deductible, 25 dollar dr. visit copay, and $17 prescriptions is $176.19.
Response to dixiegrrrrl (Original post)
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rhett o rick
(55,981 posts)GreenPartyVoter
(72,378 posts)qualify for subsidies based on the Kaiser calculator.
https://www.healthcare.gov/find-premium-estimates/#results/&aud=indv&type=med&state=ME&county=Hancock&cov=spouse